Ulcerative colitis (UC) is an inflammatory disease of the colon and rectum limited to the mucosa, and may vary in severity from a mild intermittent disease to an acute fulminant and potentially fatal disease requiring urgent surgery. Management of ulcerative colitis depends on severity, extent, and duration of the disease, response and tolerance to medication, patient age and comorbidity as well as patient preference.
Surgery plays an important role in the management of UC both because of the premalignant nature of the disease, and because of the periodic failure of medical management.
The underlying rationale for surgical treatment of the disease is that the disease is confined to the colon and rectum, and therefore proctocolectomy is curative.
The goal of surgical therapy for ulcerative colitis is to remove the disease with as little alteration of normal physiological functions and lifestyle as possible.
Four surgical options exist for patients with ulcerative colitis and each has its own advantages and disadvantages.
The surgical choices are:
Proctocolectomy and Brooke ileostomy.
Abdominal colectomy and ilcorectal anastomosis.
Proctocolectomy and Kock pouch.
Restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA).
The choice of operation requires consideration of the advantages and disadvantages of each option and must be tailored to an individual patient's needs and circumstances. Important factors to be considered in the choice of operation include the indication for surgery, age, associated medical conditions, body habitues, presence of malignancy, and quality of the anal sphincter. Extensive preoperative education is required which should include discussion with both enterostomal therapists and patients who have received similar operations previously.
There have been few randomized controlled trials in regard to surgery for ulcerative colitis (level 1 evidence). Most studies have used non-randomized concurrent controls or historic controls (level 3 & 4 evidence) or are case series (level 5).
Indications for surgery
Fulminant colitis is a severe attack of colitis with bloody diarrhoea, abdominal pain and fever. Signs of systemic sepsis such as tachycardia, hypotension, and leucocytosis are common. Massive hemorrhage may occur. Maximal medical support consisting of intravenous fluids, total parental nutrition, and intravenous steroids is the standard initial treatment if there are no signs of peritonitis. Failure of clinical improvement in 24 to 48 hour or deterioration is a strong indication for operation (level 4). Early surgical intervention has been shown to minimize the risk of complications (level 4).
Toxic megacolon is the acute dilatation of a segment of the colon with associated toxicity. The degree of dilation is not the sole factor in assessing severity but also the degree of toxicity (level 5). Though the greatest dilation is usually seen in the caecum, which can extend to 9–15 cm in toxic megacolon (level 5), it is when the transverse colon distends to greater than 6 cm where it crosses the lumbar vertebral body toxic megacolon can be diagnosed (level 4). Hypokalaemia, antidiarrhoeal medications and barium enema examinations have all been reported to predispose to development of toxic megacolon (level 5). Aggressive medical management is indicated. At least twice daily abdominal examination by experienced staff and daily radiographs are needed to exclude perforation. The majority of patients are on steroids which can make physical assessment unreliable and there may be a paradoxical decrease in the frequency of bowel motions as the condition deteriorates. Failure to improve in 24 to 48 hours, deterioration of clinical status and perforation are indications to operate (level 4). Perforation increases mortality from 4% to 40% (level 4).
Unresponsive to medical management
Ulcerative colitis in the majority of patients can be controlled by medical management. Intensive medical therapy is indicated if a patient's disease becomes unresponsive to maintenance treatment. This usually requires hospital admission and the use of intravenous steroids to induce remission. Patients who fail to respond to medical management should be considered for surgery.
Trials of cyclosporin have suggested some benefit by induction of remission but with a high rate of early relapse (level 1). At present cyclosporin should be best considered as a means of possibly converting an emergency operation into an elective operation and therefore possibly avoiding one step (emergency abdominal colectomy) of a three staged restorative procedure. Agents to modify the cytokine response are on trial at the present time and may find there way into routine clinical practice in the next few years but at present are best considered experimental, and should be used only in the context of controlled clinical trials.
Patients on long term steroids despite use of immunosuppressive agents (eg. azathioprinc) should also be considered for surgery. In addition some patients may elect for surgery because of the duration of symptoms, frequency of relapses, drug side effects or the concern about the development of malignancy in long standing disease.
Dysplasia and cancer
There is a long-term risk of patients with UC developing colorectal carcinoma (level 1). Risk depends on duration and extent of disease. After 20 years of disease the risk is approximately 3–10% and rises 1–2% yearly thereafter. Risk is highest in those with pancolitis and minimal in patients with proctitis alone. Colonosocpic surveillance aims to prevent this by screening for dysplasia, or failing this, to detect cancer at an early stage. Dysplasia usually does not occur in the first 7 to 10 years of the disease. Colonscopic surveillance with multiple random and lesion directed biopsies is recommended after this period at intervals of between one and three years. Earlier surveillance may be indicated especially with a family history of colorectal carcinoma.
The architectural and nuclear changes in dysplasia have been standardized by the Inflammatory Bowel Disease-Dysplasia Morphology Study Group. Difficulty can arise differentiating dysplasia from regenerative changes secondary to inflammation. Biopsy material should be classified as negative (normal mucosa, quiescent or active colitis), indefinite, low-grade dysplasia and high-grad dysplasia. The finding of confirmed high-grade dysplasia is an indication for resection. The finding of low-grade dysplasia or indefinite features warrants an increase in frequency of surveillance. The higher the grade of dysplasia the higher the chance of finding a coexisting carcinoma in the colectomy specimen; high grade dysplasia 40%, low grade 1–3% (level 4). Recently however it has been suggested that even low grade dysplasia should be an indication for surgery. This is at present a minority view but these findings and their significance need to be discussed with the patient who may elect to have a resection rather than continuing with intensive surveillance. One of the major problems with the endoscopic surveillance and random mucosal biopsy strategy is that up to 30% of colons removed because of the development of carcinoma will have no detectable dysplasia remote from the tumor (level 5).
Dysplasia-associated mass lesions (DAML) is the endoscopic finding of a mass, plaque or multiple closely related sessile polyps that when biopsied show evidence of either low or high-grad dysplasia (level 5). The finding of DAML is an indication for surgery because there is a greater than 50% chance of the presence of an invasive carcinoma.
Severe extraintestinal manifestations
One-third of patients with UC suffer from extraintestinal manifestations (table II). Many of the extraintestinal manifestations of UC are related to disease activity and will improve after colectomy. However neither ankylosing spondylitis or primary sclerosing cholangitis are improved with surgical resection of colonic disease.
Growth retardation in children
Severe growth retardation is reported in children with UC due to the effect of chronic illness, malnutrition and steroid use. The assessment of growth retardation can be difficult because of delayed puberty and delayed bone age. In patients with growth retardation resection is advocated prior to the closure of epiphysial plates.
There are four surgical options for ulcerative colitis all with there own advantages and disadvantages. While proctocolectomy and ileostomy has been the conventional procedure the alternatives are aimed at avoiding an incontinent stoma. The choice of which operation an individual patient should have, lies in finding the appropriate balance for them, between a stoma, bowel function and leaving residual disease.
Proctocolectomy with Brooke ileostomy
Description of procedure
This procedure involves the surgical removal of colon, rectum, and anus with creation of a permanent Brooke ileostomy.
Most patients are suitable candidates for this operation irrespective of age. The choice of this operation is often appropriate for patients who wish to avoid the problems associated with ileoanal pouch procedure (IPAA) (eg the need for a second procedure to close the stoma, risk of pouchitis, poor function, or long term risk of pouch failure) or those who are not suitable candidates for a resortative procedure, especially in elderly patients and those with poor sphincter function.
Body habitues, especially obesity can make construction of a good Brooke ileostomy difficult.
The operative technique is well described. The most important parts of the operation are the preoperative assessment of the stoma site (the aid of an enterostomal therapist is helpful), the pelvic dissection to avoid damage to the autonomic nerves of the pelvis which can cause erectile and ejaculation dysfunction, and careful anal excision as perineal wounds can be difficult to heal (level 5)
Intersphincteric perineal dissection has become the technique of choice for anal excision in these patients. With this technique the anus and distal rectum are removed through a small skin incision with the dissection being carried out in the plane between the internal and external anal sphincter. This leaves the external sphincter and levator muscle complex available for closure.
Delayed perineal wound healing is well documented as a problem (level 5). In a Mayo Clinic study of 89 patients with chronic ulcerative colitis only 61% had a healed perineal wound by thirty days, and by 200 days this had increased to 80% but 4% never healed. Intersphincteric perineal dissection improves the chance of primary healing. Proctectomy can result in damage to the pelvic autonomic nerves (impotence 5% retrograde ejaculation 3%) and dyspareunia (12–30% of females) (level 5).
Proctocolectomy with Brooke ileostomy repeatedly scores the lowest in comparative quality of life studies between the four operations (level 3). In an actuarial analysis of stomal complications in 150 patients who had their stoma for UC for 20 years, stomal complications occurred in 76% (level 5). The most common complications were skin problems (cumulative probability of 34%), retraction (17%), parastomal herniation (16%), and prolapse (11%). The cumulative probability of having a revision is 23% at 20 years.
Sexual function improves in many related to an improved overall wellbeing but the presence of a stoma is reported in 30% of ileostomomates to make sexual intercourse more difficult, and 50% feel themselves to be less sexually desirable. Despite the disadvantages, proctocolectomy with Brooke ileostomy remains a viable option in older patients and those who may not be candidates for a sphincter saving operation.
Abdominal colectomy with ileorectal anastomosis
Description of procedure
This operation involves removal of the abdominal colon with creation of an ileorectal anastomosis leaving the diseased rectum in situ and is the simplest sphincter saving operation.
The main indication for ileorectal anastomosis is the wish of the patient to avoid a permanent stoma and avoid an IPAA, either temporarily or permanently. It is a one-stage operation, with minimum hospital stay and complications. The risk of bladder and sexual dysfunction secondary to pelvic nerve injury is low.
Ileaorectal anastomosis is particularly useful in patients with indeterminate colitis when an ileostomy can be avoided, and if the disease subsequently declares itself to be Crohns Disease the optimum procedure for avoiding an ileostomy has been performed. A patient with marginal sphincter control may be better with an ileorectal anastomosis than a pouch, and it may be also be indicated in patients found to have metastatic colon carcinoma at the time of laparotomy.
The operation should not be undertaken were there is active rectal disease. The ability to make an ileorectal anastomosis requires a quiescent or minimally inflamed rectum if the procedure is to be successful. It is not a suitable operation for patients whose main symptom is frequency with uncontrolled bowel movement. It is not a suitable operation for those with colonic or rectal dysplasia (level 5).
It is a standard operative technique and is well described. The rectum should be transected at the level of the sacral promontory, and not mobilized, so as to avoid damage to the nervi erigentes, while descending over the edge of the pelvis and passing down to the inferior hypogastric plexuses.
The patients are at risk of the standard perioperative complications of a colectomy and anastomosis, and any immunosuppressed patients may be at slightly higher risk of septic complications. The most important long term problem is that of possible rectal cancer. The risk of developing a subsequent rectal carcinoma is up to 5–6% at 20 years, 15% at 30, 18% at 35 years which mandates regular endoscopic surveillance (level 5). Cancers that do present are often at an advanced stage (level 5).
Although quality of life is generally good in carefully selected patients, they do not feel as if they are cured of UC and may require chronic maintenance therapy to treat proctitis. The functional results are variable and depend on rectal compliance and the extent and activity of the UC. Good functional results are obtained in about 80–90% of carefully selected patients, with an average of 4–5 stools per 24 hours and nocturnal evacuation occurring in about 35% of patients. However, about 50% will require antidiarrheal medication although generally their function is better than that reported for ileal-anal pouches (level 5).
The cumulative probability of having a functional ileorectal anastomosis at 10 years is 50% and 20 years 32% (level 5). Failure is more common in those patients who have an ileorectal anastomosis at an younger age, and most common cause for failure is severe diarrhoea due to inflammation in the rectum. Previous ileorectostomy does not preclude a future IPAA (level 5).
Proctocolectomy with Kock pouch
Description of procedure
The Kock pouch procedure involves a standard proctocolectomy with creation of an ileal pouch with a valve to render the pouch continent. The pouch is emptied by tube intubation two to four times daily. An external appliance is not needed.
Today the main indication for a Kock pouch is in those patients seeking an alternative to a conventional ileostomy owing to skin problems or psychosocial and sexual problems, or failed ileoanal pouch procedures. Anal sphincter dysfunction or a low rectal cancer associated with UC may be suitable for a Kock pouch. It is suitable for patients who have previously undergone a proctocolectomy and Brooke ileostomy who wish conversion due to dissatisfaction with the ileostomy.
The main contraindications to the pouch are patients where there is a strong possibility of Crohns Disease due to the high rate of fistula formation, obstruction, and leakage. Relative contraindications include previous resection of a significant amount of small bowel, age of the patient over 60, co-existing serious medical illness, and obesity.
Following removal of the colon and rectum, the terminal 45 cm of ileum is used to construct the Kock pouch; 5 cm for the outlet, 10 cm for the nipple value, 30 cm for the reservoir (3 × 10 cm). An S shaped reservoir is initially constructed. The valve is created by intussusception of the terminal ileum into the pouch, with prior stripping of the mesentery and fat over the ileum that is to be made into the nipple value. The ileum is intussuscepted, and either stapled or sutured in place. The exit spout leading to the pouch can be placed in an inconspicuous location on the lower abdomen.
The main problem with the Kock pouch is the high complication rate (level 5). Reoperation rates as high as 35% within the first 2 years have been reported by experienced centers, and in centers with limited experience it is reported as being much higher. The most common problem is nipple valve dysfunction. The nipple value appears to be inherently unstable and slippage results in inability or difficulty with intubation, and usually incontinence of the pouch. The diagnosis can usually be confirmed by clinical exam or contrast study, sometimes pouchoscopy is helpful. The pouch usually needs intubation as a temporary measure and operative revision of the value as a permanent solution. Multiple variations of the Kock pouch have been described attempting to minimize the mechanical failures.
Value necrosis can occur early following construction of the pouch. It is due to ischaemia resulting from excision of the peritoneum and fat from the mesentery of the segment of ileum forming the value, or placement of staples across the mesentery and blood supply to the value.
Fistulae are reported to occur in 8–12% of patients. They may be internal or external, with the internal often involving the valve and the external usually from the pouch to the skin. The use of mesh to support the valve complex seems to be associated with a higher incidence of fistulae, however consideration of a diagnosis of Crohns Disease is important. Treatment of the fistula usually involves reoperation and excision of the value with reconstruction of a new one.
Pouchitis is not uncommon occurring between 8–42% of patients. The variable incidence reported is probably due to the variability in definition, small numbers of patients and short follow-up in most studies. Pouchitis is characterized by diarrhoea, abdominal cramps and fever, and usually responds to metrondazole.
Overall the level of satisfaction with a well functioning Kock pouch is excellent (level 3). Quality of life studies show that Kock pouch patients performed better than Brooke ileostomy patients in terms of sport and sexual function, but not as well as patients after ileoanal pouch operations. In a Cleveland Clinic study 80% of patients felt that their body image was improved after conversion of their conventional ileostomies. The main problem with the procedure is the high rate of complications requiring revisional surgery.
Restorative proctocolectomy with ileal pouch-anal anastomosis
Description of procedure
The operation involves resection of the colon and rectum, with formation of an ileal pouch, and pouch-anal anastomosis (IPAA). The procedure was first described by Sir Alan Parks of St Mark's Hospital in London.
IPAA is now the surgical procedure of choice in most patients with UC (level 3).
Patients less than 60 years of age are preferred (level 4). Exceptions have been made in extremely physiological fit individuals with acceptable results. Short obese patients are advised to lose weight prior to operation as the ability of the ileal pouch to reach the anus for anastomosis is compromised by the limited mobility of a short thick small bowel mesentery. Tall patients can also be a challenge to get the pouch to reach the anus for anastomosis.
Other contraindications include low rectal cancer, and patients where there is serious concern that the underlying diagnosis might be Crohns Disease. Ileoanal pouch failure is common if Crohns Disease is diagnosed after a pouch has been constructed then management should be aimed at the Crohns Disease itself, and the pouch doesn't have to be removed unless there is a major problem with function or fistula. In patients with UC and rectal cancers, mucosectomy is required to remove all the dysplasic mucosa, and any post operative radiotherapy may affect ileal pouch compliance, resulting in poor function. The anal sphincter needs to be of good quality. If there is any question, anal manometery should be performed. Patients who have psychological problems, emotional instability, poor motivation or are non-compliant may have difficulty adjusting to the psychological stress associated with an ileoanal pouch, and should be carefully evaluated before surgery.
Since its creation, the operation has undergone multiple modifications to improve functional results. The operation is usually undertaken in two stages, the first being the proctocolectomy, ileal pouch construction, pouch-anal anastomosis, and formation of a defunctioning loop ileostomy. The second stage is usually undertaken 2–3 month latter and consists of closure of the loop ileostomy. There are select patients who have undergone a single-stage operation with acceptable results, however peripouch sepsis with resulting fibrosis, can lead to loss of pouch compliance and poor function (level 5). This is the commonest cause for pouch failure and as such most surgeons prefer to defunction the pouch, as it reduces the chance of complications should a leak occur.
The ileal pouch is constructed using one of the several pouch designs, which include the J-pouch, S-pouch and W-pouch. The ultimate choice of pouch design is largely the surgeon's preference, studies to date suggesting that J and W produce similar results. The S pouch is considered an inferior design, especially when there is a long exit spout, as this can cause obstructive defecation problems which at times require intubation of the pouch to empty it (level 3). The J-pouch design is the most commonly used in part due to the ease of construction.
The choice of pouch-anal anastomosis is controversial. There are two options either a transanal mucosectomy with hand-sutured anastomosis between the pouch and the dentate line or a stapled technique with the anastomosis 1.5–2 cm above the dentate line preserving part of the anal transition zone. The mucosectomy technique was thought to remove all the diseased mucosa and climinate the risk of cancer, however recent evidence suggests that despite surgical mucosectomy, rests of mucosa still exist and so there is in persisting need for postoperative surveillance. Advocates of the stapled techniques suggest that it is technically easier and has better functional results. To date the published randomized and case control studies demonstrate no significant long functional differences between the two techniques, however there are a number of studies in progress (level 2).
Mortality from the operation is less than 1%. The most common complications of IPAA are pelvic sepsis, small bowel obstruction, stricture, and pouchitis (level 5). Perioperative pelvic sepsis occurs in 5–8% of patients. Poor nutritional status and immunosuppressive medications such as prednisone, cyclosporin and azathioprine are predisposing factors. Many patients can be treated by CT guided catheter drainage and antibiotics. The functional outcome after IPAA complicated by pelvic sepsis is poor.
Bowel obstruction is common following all types of surgery for UC. The annual risk for patients following IAPP is 1 in 25, 1 in 49 for a Kock pouch, 1 in 66 for a proctocolectomy and Brooke ileostomy, and 1 in 71 for colectomy and ileorectal (level 5).
Anastomotic stricture occurs in 4–16% of patients. Some degree of anal stricture may be found at the time of ileostomy closure, which is best treated by gentle dilatation. Predisposing factors include pelvic sepsis, anastomotic tension and ischaemia. The stricture may cause outlet obstructive symptoms, diarrhoea, and anal pain. The vast majority respond to dilatation, though in 60% this may have to be repeated.
Pouchitis is a condition characterized by increased stool frequency, bloody stools, abdominal cramps or pain, and fever. The aetiology is unknown. The incidence varies from 7% to 50% according to the definition of pouchitis used and the duration of follow-up. The Mayo Clinic reported, that the cumulative risk of acute pouchitis was 15% at one year, 36% at five years, and 46% at 10 years. Pouchitis is most common in patients with primary sclerosing cholangitis (PSC) and who are ANCA positive. Metronidazole is the treatment of first choice. Many other treatments in refractory cases have been used such as ciprofloxacin, corticosteroids, amoxycillin/clavulinic acid, erythromycin, tetracycline, allopurinol, 5-aminoacetic acid, short-chain fatty acids enemas and cyclosporin retention enemas. It is rare for pouchitis alone to be the cause of IPAA failure and excision.
In experienced hands, the results with IPAA are good. Stool frequency is typically 5–7 per 24 hours, including 1 bowel motion at night. Gas/stool discrimination is possible in 60–75% of patients. Day time incontinence where present is usually minor, however at night 20–25% of patients wear a pad. Antidiarrheal medications is common in the first year with 50–75% taking medication daily however after a year this falls to 25–30%. Day and night time function may improve over a year after which it remains stable for at least ten years (level 5). The early decrease in stool frequency is most likely due to the pouch expansion and the improvement in sphincter function that is seen over the first year.
Pouch failure is infrequent reported at between 2–9% over 10 years (level 5). The most common reasons for pouch failure are pelvic sepsis, gross faecal incontinence, Crohns Disease, and chronic pouchitis.
Pregnancy and vaginal delivery are possible and do not affect the long term results after IAPP (level 5). Although the frequency of nocturnal stooling increases during pregnancy, neither daytime stool frequency nor continence appear to be adversely affected, and neither vaginal delivery or caesarean section appears to adversely affect longer term pouch function.
Quality of life in patients with IPAA is better than that of patients with Brooke ileostomies, Kock pouches and medically treated patients with UC (level 3). It is the combination of good functional results and quality of life which argues strongly in support of IPAA as the operative procedures of choice in UC.
There are multiple situations which warrant special consideration with regard to the surgical management of UC.
There are cases in which there are histologic features of both UC and Crohns Disease which is termed “indeterminate colitis”. All attempts to differentiate UC from Crohns Disease should be made preoperatively. This is important because IPAA and the Kock pouch should not be performed for Crohns Disease. All endoscopic, radiographic and pathologic information should be reviewed carefully preoperatively. If the diagnosis is in question the rectum can be left as a Hartmann's pouch and an ileostomy created. This leaves the option for future IPAA, ileorectostomy, or completion proctectomy. In cases where there is convincing evidence of Crohns Disease proctocolectomy with Brooke ileostomy or ileorectostomy should be undertaken. In patients whith indeterminate colitis which has behaved like ulcesative colitis undergo IPAA, the functional outcome and failure rates are similar to that observed for UC (level 5).
Primary sclerosing cholangitis
Primary sclerosing cholangitis (PSC) is the most common hepatobiliary condition associated with UC. PSC may lead to biliary cirrhosis and portal hypertension. Stomas of any kind, in particular ileostomies, should be avoided due to the development of stomal varices. Proctocolectomy with ileostomy is associated with an approximate 50% incidence of bleeding complications from the stoma and stomal varices (level 5).
Given the opportunity, IPAA or ileorectal anastomosis are preferred over the creation of a stoma (level 4). Varices with IPAA although theoretically possible have not been reported. Patients with UC and PSC treated by IPAA do have a higher incidence of pouchitis. The course of PSC is not influenced by colectomy and patients may eventually require liver transplantation or develop complicating cholangiocarcinoma.
Colon and rectal carcinomas
The finding of a colon or rectal cancer in a patient with UC is unfortunate. Colon cancers of relative early stage (Dukes A or B) can be treated by proctocolectomy and IPAA, Kock pouch or Brooke ileostomy (level 5). Metastatic colon tumors to the liver should be treated with proctocolectomy with Brooke ileostomy or abdominal colectomy and ileorectal anastomosis. The treatment of patients who are lymph node positive (Dukes C) is best by proctocolectomy and Brooke ileostomy. If the patient is very adverse to a stoma, IPAA could be carried out.
Rectal carcinoma in the middle and lower rectum is a contraindication for IPAA. A standard proctectomy is advisable and a permanent Brooke ileostomy. These patients are prone to local recurrence, and thus radiation therapy may be required in the future. Patients with upper rectal tumors may safely undergo IPAA, but in the case of a large, advanced tumor, proctocolectomy with Brooke ileostomy is advisable (level 5).
Fulminant colitis and toxic megacolon may prompt emergency surgery in UC. The treatment of choice is abdominal colectomy and Brooke ileostomy with rectal preservation which allows a subsequent IPAA. It is important to preserve the ileocolic artery, and not to dissect in the pelvis. It is helpful to bring the rectal stump out as a mucus fistula, to help prevent rectal stump blowout, and for subsequent ease of dissection. There is a risk of persistent sepsis and bleeding from the rectal stump which may require subsequent proctectomy. IPAA under emergency conditions can be safely performed in highly selected patients.
Surgical management of UC requires a complete understanding of the potential operative procedures. The decision when to operate requires careful consideration from patient, gastroenterologist and surgeon. The choice of operation is determined by the particular circumstances of the individual patient. IPAA is the procedure of choice in most case of UC. Good functional results and patient satisfaction with IPAA are generally the rule. Ileorectal anastomosis and proctocolectomy with Brooke ileostomy or Kock pouch also have their place in the surgical management of selected cases.
- Hanauer S B. Inflammatory bowel disease. N Engl J Med. (1996);334:841–848. [PubMed: 8596552]
- Hyde G M, Thillainayagam A V, Jewell D P. Intravenous cyclosporin as rescue therapy in severe ulcerative colitis: time for a reappraisal? European Journal of Gastroenterology & Hepatology. (1998);10:411–413. [PubMed: 9619388]
- Selby W. Clinical perspectives in inflammatory bowel disease. Aust NZ J Med. (1996);26:15–19. [PubMed: 8775523]
- Hill G L, Neill M E. What should the non-colorectal surgeon do when faced with a patient with acute fulminating colitis? Aust NZ J Surg. (1996);66:1–3. [PubMed: 8629970]
- Biasco G, Brandi G, Paganelli G M, Rossini F P, Santucci R, Di Febo G, Miglioli M, Risio M, Morselli Labate A M, Barbara L. Colorectal cancer in patients with ulcerative colitis. A prospective cohort study in Italy. Cancer. (1995);75:2045–2050. [PubMed: 7697592]
- Ziv Y, Fazio V W, Sirimarco M T, Lavery I C, Goldblum J R, Petras R E. Incidence, risk factors, and treatment of dysplasia in the anal transitional zone after ileal pouch-anal anastomosis. Dis Colon Rectum. (1994);37:1281–1285. [PubMed: 7995159]
- Solomon M J, Schnitzler M. Cancer and inflammatory bowel disease: bias, epidemiology, surveillance, and treatment. World J Surg. (1998);22:352–358. [PubMed: 9523516]
- Hulten L. Proctocolectomy and ileostomy to pouch surgery for ulcerative colitis. World J Surg. (1998);22:335–341. [PubMed: 9523513]
- Leong A P, Londono-Schimmer E E, Phillips R K. Life-table analysis of stomal complications following ileostomy. Br J Surg. (1994);81:727–729. [PubMed: 8044564]
- Paoluzi O A, Di Paolo M C, Ricci F, Pasquali C, Iacucci M, Paoluzi P. Ileorectal anastomosis in ulcerative colitis: results of a long-term follow-up study. Italian J Gastroenterology. (1994);26:392–397. [PubMed: 7703514]
- Pastore R L, Wolff B G, Hodge D. Total abdominal colectomy and ileorectal anastomosis for inflammatory bowel disease. Dis Colon Rectum. (1997);40:1455–1464. [PubMed: 9407985]
- Sandborn W J. Pouchitis following ileal pouch-anal anastomosis: Definition, pathogenesis, and treatment. Gastroneterology. (1994);197:1858–1860. [PubMed: 7958702]
- Ziu Y, Fazio V W, Church J M, Lavery I C, King T M, Ambrosetti P. Stapled ileal pouch anal anastomoses are safer than handsewn anastomoses in patients with ulcerative colitis. Am J Surg. (1996);171:320–323. [PubMed: 8615465]
- Reilly W T, Pemberton J H, Wolff B G, Nivatvongs S, Devine R M, Litchy W J, McIntyre P B. Randomized prospective trial comparing ileal pouch-anal anastomosis performed by excising the anal mucosa to ileal pouch-anal anastomosis performed by preserving the anal mucosa. Annals of Surgery. (1997);225:666–677. [PMC free article: PMC1190866] [PubMed: 9230807]
- Stahlberg D, Gullberg K, Liljeqvist L, Hellers G, Lofberg R. Pouchitis following pelvic pouch operation for ulcerative colitis. Incidence, cumulative risk, and risk factors. Dis Colon Rectum. (1996);39:1012–1018. [PubMed: 8797652]
- Mignon M, Stettler C, Phillips S F. Pouchitis - a poorly understood entity. Dis Colon Rectum. (1995);38:100–193. [PubMed: 7813336]
- Farouk R, Dozois R R, Pemberton J H, Larson D. Incidence and subsequent impact of pelvic abscess after ileal pouchanal anastomosis for chronic ulcerative colitis. Dis Colon Rectum. (1998);41:1239–1243. [PubMed: 9788386]
- McIntyre P B, Pemberton J H, Wollf B G, Dozois R R, Beart R W. Indeterminatic colitis. Long-term outcome in patients after ileal pouch-anal anastomosis. Dis Colon Rectum. (1995);38:51–54. [PubMed: 7813345]
- McLeod R S, Baxter N N. Quality of life of patients with inflammatory bowel disease after surgery. World J Surg. (1998);22:375–381. [PubMed: 9523520]
F.A. Frizelle, MBChB, MMedSci, FRACS1 and M.J. Burt, MBChB, Ph.D., FRACP2.
Frizelle FA, Burt MJ. Surgical management of ulcerative colitis. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001.